The Witness Project

Breast cancer screening through annual mammography and breast physical examinations is highly successful in diagnosing early onset of the disease and improving survival rates among women over 50. However, among ethnic minority groups such as African American women, particularly in rural areas, there are barriers to participation in these screening activities. For African American women, particularly in rural areas, these include economic barriers, problems with transportation, access-related factors, inconvenience and lack of time, lack of physician recommendation, psychological factors such as fear and fatalism, lack of knowledge and awareness of breast cancer, and misunderstanding of recommended screening frequency. Factors such as these contribute to African American women's higher rates of mortality in all stages of breast cancer, despite the fact that they have a somewhat lower incident rate of breast cancer overall. The Witness Project is a theory-based program designed specifically for African Americans to increase awareness and screening for breast cancer. This program has been implemented in many states across the country.

Note:  While breast self examination (BSE) has not been shown to be an effective early detection method, BSE training and processes are used in the educational program and agenda of the Witness Project as a behavior change modifier that has been shown to lead African American women to: 1) be more comfortable with their bodies and pay more attention to changes that might occur and 2) be more likely to decide to obtain clinical breast examinations (CBE) and mammograms. (Bloom JR, Grazier K, Hodge F, Hayes WA: Factors affecting the use of screening mammography among African-American women. Cancer Epidemiology Biomarkers and Prevention 1:75-82, 1991)

The Witness Project is a culturally informed, community-based breast and cervical cancer education program. It is designed to effectively increase awareness, knowledge, and motivation, thereby increasing screening and early-detection behaviors among African American women and ultimately reducing mortality and morbidity from breast and cervical cancer. The information is formatted for various learning styles. Material is presented sequentially through story-telling with experiential learning techniques, rather than as a traditional didactic presentation, to appeal to adult learners with limited formal education. The Witness Project involves a team of local African American breast and cervical cancer survivors, "Witness Role Models" (WRMs), who speak to groups of other African American women at local churches and community organizations in rural areas. Church-based programs, held immediately after worship services, or concurrently with the Sunday School session, or at other regularly scheduled activity times, begin and end with a hymn and a prayer. Each witness role model in turn (two to five per program) talks to the group about her personal experience, highlighting early detection and treatment, and incorporating a spiritual context. The importance of taking responsibility for one's own health (empowerment and assertiveness) and the need to spread these messages throughout the African American community are emphasized. Participants are also taught breast self-examination using ethnic breast models and are given information about early detection and breast and cervical cancer screening services. While BSE has not been shown to be an effective early detection method, BSE training and processes are used in the educational program and agenda of the Witness Project as a behavior change modifier that has been shown to lead African American women to be 1) more comfortable with their bodies and paying more attention to changes that might occur, and 2) more likely to go on to decide to obtain clinical breast examinations (CBE) and mammograms. (Bloom JR, Grazier K, Hodge F, Hayes WA: Factors affecting the use of screening mammography among African-American women. Cancer Epidemiology Biomarkers and Prevention 1:75-82, 1991).

Implementation of The Witness Project requires advance preparation for recruiting and training Witness Role Models (WRMs) and Lay Health Advisors (LHAs). The Witness Project is conducted over one program session presented in a church or community center. WRMs and LHAs participate in an 8-hour training curriculum as outlined in the Witness Project Facilitator Training Manual. Staff from The Witness Project (a) conduct site visits with partners for the purpose of assessment for technical assistance and follow-up, (b) collaborate with partners to determine the effectiveness of the evaluation process for the Witness Project, and (c) provide feedback reports as a result of site visits and any technical assistance required.

The program was originally designed for use in rural Arkansas to meet the specific cultural, educational, knowledge, and learning styles of underserved African American women. Although the intervention is aimed at women over the age of 40, women younger than age 40 and men are not excluded from attending the intervention, as it is conducted in a community setting in the interest of addressing the health education messages to the total social and cultural environment of the participants. It has since been disseminated and replicated with African American women in a wide variety of locations and organizations in the United States, showing that the culturally tailored components of the model appear to be generalizable to and appropriate for multiple African American communities.

The intervention is suitable for implementation in church- and community-based settings.

An implementation guide, facilitator training manual, and systematic coaching, training, and technical assistance are available.

The Witness Project has been implemented in 25 sites with 401 volunteers, delivering cancer education and screening programs to over 10,000 women. One quasi-experimental pretest and post-test study was conducted for rural, underserved women in eastern Arkansas. Key findings include:

• Mammography screening behavior was examined for women age 40 years and older, with results indicating a significant increase in ever having had a mammogram for the intervention group (baseline: 52.4 percent, follow-up: 64.4 percent), but no significant difference from baseline (60.4 percent) to follow-up (63.3 percent) in the control group.